1250 SE Maynard Road, Ste. 204
Cary, NC 27511


Ph: 919-371-4378
Fax 919-300-7943

www.slteletherapy.com

 
SELF-PAY AGREEMENT
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The Self-Pay Agreement is intended to provide Self-Pay patients/Financial Power of Attorney with an understanding of the financial aspect of healthcare services provided by Silver Linings Therapists.  Self-Pay patients and Financial Power of Attorneys should read this agreement carefully before deciding and proceeding with services.
  • Self-Pay patient/Financial/Power of Attorney will receive a bill from Silver Linings for healthcare services provided by a Silver Linings Therapist. 
  • Self-Pay patient/Financial Power of Attorney will be required to have a credit card on file even if they pay by check.  Payment is due prior to services being rendered.  Any outstanding balances on account must be paid prior to a new session being scheduled.
  • Self-Pay patient/Financial Power of Attorney will be responsible for full payment of charges at the rate of $120. 00 per Mental Health Clinical assessment and $80.00 for a 60-minute Therapy/Counseling session.
  • Silver Linings will not bill any insurance plan if the Self-Pay patient/Financial Power of Attorney elects to be Self-Pay at the time of service.  
    • However, if an existing client that has elected to be Self-Pay, later decides they want to start using insurance, Silver Linings front office will receive a copy of your insurance card and verify the insurance benefits.  Regardless of the outcome, Silver Linings will continue to bill the client’s credit card until the insurance has begun to pay.  Silver Linings will then refund any monies paid in duplicate to the client and stop billing the client except for monies owed after insurance has paid.  The client must agree to pay at the Self-Pay rate until the insurance starts to pay and if the insurance declines payment for any reason.
    • No claim will be sent to my insurance since it’s my personal decision not to use my health insurance benefits for the above service/therapy, even though I understand that these services/ therapies may be considered covered by my policy (Elective Self-Pay).
    • THIS AGREEMENT EXCLUDES MEDICARE/MEDICARE ADVANTAGE PLAN BENEFICIARIES. 
 

The patient has been registered as Self-Pay due to the following reason marked below: 

The patient/Financial Power of Attorney does not have insurance coverage OR

The provider performing the above services or therapies is not a participating provider with my health insurance.  Therefore, these services/therapies are not covered by my policy. 

It is my personal decision not to obtain the authorization from my primary care physician and not to have Silver Linings obtain it on my behalf.  I agree to pay Silver Linings for services.

My signature below acknowledges receipt and acceptance of the Self Pay Agreement 

Signature Instructions:
Touch Screen: use finger or stylus to sign
Desktop Monitor: use mouse or touchpad to sign

 
 

Staff Signatures:

Date: